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HomeMy WebLinkAbout0988DOCUMENT CONVERSION SERVICES PROVIDED BY IMAGING & MICROFILM ACCESS, INC. www.scanyourdocs.com 631- 589 -8100 25.46 -1 -57 BOX 10 064NER' S NAME PUTNAM COUNTY HEALTH DEPARTMENT DIVISION OF ENVIRONMENTAL HEALTH SERVICES PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR PHONE 271°j -;'0 lI SITE LOCATION / ,:�- o Ve -l-V -1, y Lc%A 7M# MAILING ADDRESS Qo�Af UV �v� -r•e �•,., Ic,�t• �., PERSON INTERVIEWED Pall) Complaint $ Name & Relationship (i.e, owner,tenant, etc.) p DATE T- 1 = G l UU TYPE FACILITY PROPOSED INSTALLER �` S`�`� a� � • � ��c . PHONE REGISTRATION # IU( Proposal (include sketch locating all adjacent wells): NOTE: Repair must be in same location and of same type as original sewage disposal system. Different location may require submittal of proposal fran licensed professional engineer or registered architect. _ _ —t I It n ► ► t k . k 's Siqnature & T Proposal Disapproved i7flL Proposal approved with the following conditions: 1. Procurement of any Town permit, if applicable. 2. Submission of as built repair sketch in duplicate showing: a. Owner's name. b. Site Street Name, Town and Tax Map number. c. Location of installed components tied to two fixed points (e.g.,house corners). d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diam. x 6' deep drywells surrounded by one foot + gravel). e. Installer's name and number. 3. System repair to be performed in accordance with the above proposal and conditions. I, as owner, or rep agent of owner agree to the above conditions. SIGNATURE TITLE C L DATE O MM: W-dte (PCID): Yellow (An ffi); Pink (,k#iCBnt) D c� I D Ice- ! i� 0 0cC,. , n� PC, i4e rSoM.. A- GMl- fi"y �� f-2 Itl CK - 0// t. g-j K C n�c C i� ►� = 3.1 (3 = 3£R'